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8/4/2019 Physical Assessment of Cg
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PHYSICAL ASSESSMENT OF CG
PHYSICAL ASSESSMENT NORMS ACTUAL FINDINGS INTERPRETATIO
AND ANALYSI
APPEARANCE AND MENTAL
STATUS
1. Body build, height, andweight in relation to
clients age, lifestyle,
and health
2. Clients posture andgait, standing, sitting,
and walking
3. Overall hygiene andgrooming. Relate these
to the persons
activities prior to the
assessment
4. Body and breath odorin relation
5. Distress in posture orfacial expression
6. Obvious signs of healthor illness
7. Clients response
8. Clients affect/mood;appropriateness of the
clients responses
Proportionate, varies
with lifestyle
Relaxed, erect posture;
coordinated movement
Clean and neat
No body odor or minor
body odor relative to
work or exercise; no
breath odor
No distress note
Healthy appearance
Cooperative and able to
follow instructions
Appropriate to situation
Body build, height, and
weight is proportion in age
and varies with lifestyle
Relaxed, erect posture;
coordinated movement
Clean and neat
No body odor or minor body
odor relative to work or
exercise; no breath odor
No distress note
Healthy appearance
Cooperative and able to
follow instructions
Appropriate to situation
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
8/4/2019 Physical Assessment of Cg
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9. Quantity, quality, andorganization of speech
10.Listen to relevance andorganization of
thoughts
Understandable,
moderate pace; clear
tone and inflection;
exhibits thought
association
Logical sequence; makes
sense; has sense of
reality
Understandable, moderate
pace; clear tone and
inflection; exhibits thought
association
Logical sequence; makes
sense; has sense of reality
Normal
Normal
VITAL SIGNS
1. Temperature2. Pulse rate3. Respiratory rate4. Blood pressure
35.5 - 37. 5o
c
60-100 bpm (adult)
12-20 bpm (adult)
120/80 mmHg
36.8o
c
66 bpm
14 bpm
120/80 mmHg
Normal
Normal
Normal
Normal
SKIN
1. Skin color
2. Uniformity of skin color
3. Presence of edema4. Skin lesions
Varies from light to deep
brown; from ruddy pink
to light pink; from yellow
overtones to olive
Generally uniform except
in areas exposed to the
sun; areas of lighter
pigmentation in dark
skinned people
Absence of edema
Freckles, some
birthmarks, some flat
and raised nevi; no
abrasions or other
lesions
Skin color varies from light
to deep brown
Generally uniform except in
areas exposed to the sun;
there are areas of lighter
pigmentation
Absence of edema
Absence of freckles, some
birthmarks, some flat and
raised nevi; no abrasions or
other lesions
Normal
Normal
Normal
Normal
8/4/2019 Physical Assessment of Cg
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5. Skin moisture
6. Skin temperature
7. Skin turgor
Moisture in skin folds
and the axillae
Uniform; within normal
range
When pinched, skin
springs back to previous
state; may be slower in
elders
Moisture in skin folds and
the axillae
Uniform; within normal
range
When pinched, skin springs
back to previous state
Normal
Normal
Normal
HAIR
1. Evenness of growthover the scalp
2. Hair thickness orthinness
3. Hair texture andoiliness
4. Presence of infectionsor infestations
5. Amount of body hair
Evenly distributed
Thick hair
Silky , resilient hair
Absence of infection or
infestation
Variables
Evenly distributed
Thick hair
Silky , resilient hair
Absence of infection or
infestation
Variables
Normal
Normal
Normal
Normal
Normal
NAILS
1. Plate shape, curvatureand angle
2. Texture3. Color
4. Tissues surroundingthe nails
5. Blanch test capillaryrefill
Convex curvature; angle
of nail about 160o
Smooth texture
Highly vascular and pink
Intact epidermis
Prompt return of pink
Convex curvature; angle of
nail about 160o
Smooth texture
Highly vascular and pink
Intact epidermis
Prompt return of pink
Normal
Normal
Normal
Normal
Normal
8/4/2019 Physical Assessment of Cg
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SKULL AND FACE
1. Skull size, shape andsymmetry
2. Skull of nodules ormasses and
depressions
3. Facial features
4. Eyes for edema andhollowness
5. Symmetry of facialmovements
Rounded, smooth skull
contour
Smooth, uniform
consistency; absence of
nodules or masses
Symmetric or slightly
asymmetric facial
features; palpebral
fissures are equal in size;
symmetric nasolabial
folds
Absence of edema and
hollowness
Symmetric facial
movements
Rounded, smooth skull
contour
Smooth, uniform
consistency; absence of
nodules or masses
Symmetric facial features;
palpebral fissures are equal
in size; symmetric nasolabial
folds
Absence of edema and
hollowness
Symmetric facial movements
Normal
Normal
Normal
Normal
Normal
EYES STRUCTURES AND
VISUAL ACUITY
1. Hair distribution,alignment, skin quality
and movement
2. Evenness distributionof the eyelashes and its
direction or curl
3. Surface characteristicsof the eyelids
Hair is evenly distributed;
skin is intact; eyebrows
are symmetrically
aligned; equal movement
Equally distributed;
curled slightly outward
Skin is intact; no
discharge; no
discoloration; lids close
symmetrically;
approximately 15 - 20
involuntary blinks per
minute; bilateral blinking;
when lids are open, no
Hair is evenly distributed;
skin is intact; eyebrows are
symmetrically aligned; equal
movement
Equally distributed; curled
slightly outward
Skin is intact; no discharge;
no discoloration; lids close
symmetrically; 13
involuntary blinks per
minute; bilateral blinking;
when lids are open, no
visible sclera and lower
borders of cornea are
Normal
Normal
Normal
8/4/2019 Physical Assessment of Cg
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4. Bulbar conjunctiva
5. Palpebral conjunctiva
6. Lacrimal gland
7. Lacrimal sac andnasolacrimal duct
8. Clarity and texture ofthe cornea
9. Cornea sensitivity
10.Transparency anddepth of the anterior
chamber
11.Color, shape andsymmetry of size of the
pupil
12.Third (Oculomotor)and forth (trochlear)
cranial nerve
pupils directand consensual
visible sclera and lower
borders of cornea are
slightly covered
Transparent; capillaries
sometimes even evident;
sclera appears white
Shiny smooth and
pink/red
Absence of edema or
tenderness over Lacrimal
gland
Absence of edema or
tearing
Transparent, shiny and
smooth; details of iris are
visible
Blinks when cornea is
touched, indicating that
the trigeminal nerve is
intact
Transparent
Black in color, equal in
size, normally 3 - 7
diameter; round, smooth
border, iris flat and
round
Illuminated pupil
constricts (direct
response)
slightly covered
Transparent; sclera appears
white
Shiny smooth and pink
Absence of edema or
tenderness over Lacrimal
gland
Absence of edema or tearing
Transparent, shiny and
smooth; details of iris are
visible
Blinks when cornea is
touched, indicating that the
trigeminal nerve is intact
Transparent
Black in color, equal in size, 4
in diameter; round, smooth
border, iris flat and round
Illuminated pupil constricts
(direct response)
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
8/4/2019 Physical Assessment of Cg
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reaction to light
13.Pupils reaction toaccommodation
14.Peripheral visual To determine
function of the
retina and
neuronal visual
pathways to the
brain and
second (optic)
cranial nerve
15.Six ocular movements
16.Corneal light reflex
17.Cover test
18.Near vision test19.Distance vision
Snellens chart
Non-illuminated pupil
constricts ( consensual
response)
Pupils constricts when
looking at near object;
pupil dilates when
looking at far objects;
pupils converge when
near object is moved
toward the nose
When looking straight
ahead, client can see
objects in the periphery
Both eyes coordinated,
move in unison with
parallel alignment
Light fall symmetrically
on both pupils
Uncovered eye does not
move
20/20 vision
Non-illuminated pupil
constricts ( consensual
response)
Pupils constricts when
looking at near object; pupil
dilates when looking at far
objects; pupils converge
when near object is moved
toward the nose
When looking straight
ahead, client can see objects
in the periphery
Both eyes coordinated,
move in unison with parallel
alignment
Light fall symmetrically on
both pupils
Uncovered eye does not
move
20/20 vision
Normal
Normal
Normal
Normal
Normal
Normal
Normal
EARS AND HEARING
1. Auricles for color,symmertry of size and
position
The color is same as
facial skin; symmetrical;
auricles aligned with
outer canthus of the eye,
about 10o
from vertical
The color is same as facial
skin; symmetrical; auricles
aligned with outer canthus
of the eye, about 10o
from
vertical
Normal
8/4/2019 Physical Assessment of Cg
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2. Auricles for texture,elasticity, and areas of
tenderness
3. External ear canal forcerumen, skin lesions,
pus and blood
4. Tympanic membranefor color and gloss
5. Response to normalvoice tones
6. Watch tick
7. Webers test
8. Rinnes test
Mobile, firm, and not
tender;; pinna recoils
after it is folded
Distal third contains hair
follicles and glands; dry
cerumen, grayish tan
color, sticky, wet
cerumen in various
shades of brown
Pearly gray color,
semitransparent
Normal voice tones
audible
Able to hair ticking in
both ears
Sound is heard in both
ears or is localized at the
center of the head
Air-conducted hearing is
greater than bone-
conducted hearing
Mobile, firm, and not
tender;; pinna recoils after it
is folded
Distal third contains hair
follicles and glands; dry
cerumen, grayish tan color,
sticky, wet cerumen in
various shades of brown
Pearly gray color,
semitransparent
Normal voice tones audible
Able to hair ticking in both
ears
Sound is heard in both ears
or is localized at the center
of the head
Air-conducted hearing is
greater than bone-
conducted hearing
Normal
Normal
Normal
Normal
Normal
Normal
Normal
MOUTH AND OROPHARYNX
1. Symmetry of contour,color and texture of
outer lips
2. Color, moisture,texture and presence
of lesions in the inner
lips and buccal
Uniform pink color; soft,
moist, smooth texture;
symmetry of contour;
able to purse lips
Uniform pink; moist,
smooth, soft, glistening,
and elastic texture
Uniform pink color; soft,
moist, smooth texture;
symmetry of contour; able
to purse lips
Uniform pink; moist,
smooth, soft, glistening, and
elastic texture
Normal
Normal
8/4/2019 Physical Assessment of Cg
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3. Teeth and gums
4. Dentures
5. Surface, position, colorand texture of the
tongue
6. Tongue movement
7. Base of the tongue, themouth floor and the
frenulum
8. Any nodules, lumps oroxcoriated areas in the
tongue and floor of the
mouth
9. Salivary duct openingsfor any swelling or
redness
10.Color, shape, textureand the presence of
bony prominences on
the hard and soft
palate
11.Position and mobilityof the uvula
32 adult teeth; smooth,
white, shiny tooth
enamel; pink gums;
moist, firm texture to
gums; no retractions of
gums
Smooth, intact dentures
Central position; pink
color; moist; slightly
rough; thin, whitish
coating; smooth, lateral
margins; no lesions;
raised papillae
Moves freely; Absence of
tenderness
Smooth tongue base with
prominent veins
Smooth with no palpable
nodules
Same as color of buccal
mucosa and floor of
mouth; no presence of
any swelling or redness
Light pink, smooth, soft
palate; lighter pink hard
palate, more irregular
texture
Positioned in midline of
soft palate
27 adult teeth; smooth,
white, shiny tooth enamel;
pink gums; moist, firm
texture to gums; no
retractions of gums
Presence of smooth, intact
dentures
Central position; pink color;
moist; slightly rough; thin,
whitish coating; smooth,
lateral margins; no lesions;
raised papillae
Moves freely; Absence of
tenderness
Smooth tongue base with
prominent veins
Smooth with no palpable
nodules
Same as color of buccal
mucosa and floor of mouth;
no presence of any swelling
or redness
Light pink, smooth, soft
palate; lighter pink hard
palate, more irregular
texture
Positioned in midline of soft
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
8/4/2019 Physical Assessment of Cg
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12.Color and texture ofthe oropharynx
13.Color, discharge andsize of the tonsils
behind the fauces
14.Gag reflex
Pink and smooth
posterior wall
Pink and smooth; no
discharge; of normal size
or not visible
Present
palate
Pink and smooth posterior
wall
Pink and smooth; no
discharge; of normal size or
not visible
Present
Normal
Normal
Normal
NECK
1. Symmetrical size of themuscle
2. Head movement
3. Muscke strength4. Enlarged lymph nodes
on the entire neck
5. Lateral deviation of thetrachea
6. Thyroid gland7. Smoothness of the
thyroid gland
8. Bruit sound over thethyroid area
Muscles are equal in size;
head centered
Coordinated, smooth
movements with no
discomforts
Equal strength
Not palpable
Central placement in
midline of neck; spaces
are equal on both sides
Not visible
Small, smooth, centrally
located, painless, and
rise freely with
swallowing
Absence of Bruit
Muscles are equal in size;
head centered
Coordinated, smooth
movements with no
discomforts
Equal strength
Not palpable
Central placement in midline
of neck; spaces are equal on
both sides.
Not visible
Small, smooth, centrally
located, painless, and rise
freely with swallowing
Absence of Bruit
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
PERIPHERAL VASCULAR
SYSTEM
1. Peripheral veins Symmetric pulsevolumes. Full pulsations
Symmetric pulse volumes.
Full pulsations
Normal
8/4/2019 Physical Assessment of Cg
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2. Peripheral veins in thearms and legs for the
presence of superficial
veins when limbs are
dependent and
elevated
3. Skin of the hands andfeet, temperature,
edema and skin
changes (Peripheral
perfusion)
Presence of distention
and nodular bulges at
claves; limbs not tender;
symmetric in size
Skin color is pink; skin
temperature is not
excessively warm or cold;
no edema; skin texture is
moist and resilient
Presence of distention and
nodular bulges at claves;
limbs not tender; symmetric
in size
Skin color is pink; skin
temperature is not
excessively warm or cold; no
edema; skin texture is moist
and resilient
Normal
Normal
HEART AND THE CENTRAL
VESSELS
1. Carotid arteries
2. Jugular veins
Symmetric pulsations;
full pulsations, thrusting
quality; elastic artery
wall; no sound heard on
auscultation
Veins not visible
Symmetric pulsations; full
pulsations, thrusting quality;
elastic artery wall; no sound
heard on auscultation
Veins not visible
Normal
Normal
BREAST AND AXILLAE
1. Size, symmetry,contour or shape of
the breast
2. Localized discolorationor hyperpigmentation,
retraction or dimpling
on the breast
3. Presence welling andedema on the breast
Female: rounded shape;
slightly unequal in size;
generally symmetric
Male: Breast even in the
chest wall
Skin uniform in color;
skin is smoothly intact
Absence of swelling and
edema
Breast even in the chest wall
Skin uniform in color; skin is
smoothly intact
Absence of swelling and
edema
Normal
Normal
Normal
8/4/2019 Physical Assessment of Cg
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4. Presence of masses,tenderness and
nodules
5. Size, shape, symmetry,color, surface
characteristics of the
breast
6. Size, shape, symmetry,color, discharge and
lesions on the nipples
7. Presence of tendernessor nodules
Absence of tenderness,
nodules, masses or
nipple discharge
Round or oval and
bilaterally the same;
irregular placement of
sebaceous glands; color
varies from light pink to
dark brown
Round, everted and
equal in size; similar in
color; soft and smooth;
no discharge (except for
mother who is
breastfeeding)
Absence of tenderness,
masses or nodules
Absence of tenderness,
nodules, masses or nipple
discharge
Round or oval and bilaterally
the same; irregular
placement of sebaceous
glands; color varies from
light pink to dark brown
Round, everted and equal in
size; similar in color; soft and
smooth; no discharge
Absence of tenderness,
masses or nodules
Normal
Normal
Normal
Normal
THORAX AND LUNGS
1. Shape and symmetryof the thorax from
posterior and lateral
views
2. Spinal alignment3. Temperature and
integrity of all chest
skin
4. Lateral deviation of thespine
5. Presence of edema,tenderness and masse
Anteroposterior to
transverse diameter in
ratio of 1:2
Spine vertically aligned
Skin intact; uniform
temperature
Spinal column is straight;
right and life shoulders
and hips are at the same
height
Absence of edema,
tenderness and masses
Anteroposterior to
transverse diameter in ratio
of 1:2
Spine vertically aligned
Skin intact; uniform
temperature
Spinal column is straight;
right and life shoulders and
hips are at the same height
Absence of edema,
tenderness and masses
Normal
Normal
Normal
Normal
Normal
8/4/2019 Physical Assessment of Cg
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6. Respiratory excursionin the posterior chest
7. Vocal fremitus
8. Breathing patterns
9. Costal angle
10.Respiratory excursionin the anterior thorax
11.Tactile fremitus
12.Trachea
Full and symmetric chest
expansion
Bilateral symmetry of
vocal fremitus
Quiet rhythmitic,
effortless respiration
Costal angle is less than
90o
and the ribs insert
into the spine at
approximately 45o
Full symmetric excursion
Fremitus is normaly
decreased over heart and
breast tissue
Brochial and tubular
breath sounds
Full and symmetric chest
expansion
Bilateral symmetry of vocal
fremitus
Quiet rhythmitic, effortless
respiration
Costal angle is less than 90o
and the ribs insert into the
spine at approximately 45o
Full symmetric excursion
Fremitus is present
Brochial and tubular breath
sounds
Normal
Normal
Normal
Normal
Normal
Normal
Normal
ABDOMEN
1. Skin integrity
2. Presence of striae3. Contour and symmetry
4. Abdominal movementsassociated with
respiration, peristalsis
or aortic pulsation
Unblemished skin color;
uniform color
Absence of striae
Flat, rounded (convex) or
scaphoid (concave);
symmetric contour
Symmetric abdominal
movements caused by
respiration; visible
peristalsis in lean people;
aortic pulsations in thin
persons in epigastric area
Unblemished skin color;
uniform color
Presence of striae
Flat, rounded (convex) or
scaphoid (concave);
symmetric contour
Symmetric abdominal
movements caused by
respiration
Normal
Not normal
Normal
Normal
Normal
8/4/2019 Physical Assessment of Cg
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5. Vascular pattern
6. Bowel sounds, vascularperitoneal friction rubs
7. Abdomen percussion
8. Liver percussion
9. Light palpation on theabdomen
10.Deep palpation on theabdomen
11.Liver palpation
12.Bladder palpation
No visible vascular
pattern
Audible bowel sounds;
absence of arterial bruits;
absence of friction rub
Tympany over the
stomach and gas-filled
bowels; dullness over the
liver and spleen
6 - 12 cm in the
midclavicular; 4-8 cm at
the midsternal line
Absence of tenderness;
relaxed abdomen with
smooth, consistent
tension
Tenderness may be
present near the xiphoid
process, over cecum, and
over sigmoid colon
May not be palpable,
borders feels smooth
Not palpable
No visible vascular pattern
Audible bowel sounds;
absence of arterial bruits;
absence of friction rub
Tympany over the stomach
and gas-filled bowels;
dullness over the liver and
spleen
8 cm in the midclavicular; 8
cm at the midsternal line
Absence of tenderness;
relaxed abdomen with
smooth, consistent tension
Tenderness is present near
the xiphoid process, over
cecum, and over sigmoid
colon
Not palpable
Not palpable
Normal
Normal
Normal
Normal
Normal
Normal
Normal
MUSCULOSKELETAL SYSTEM
1. Muscle size
2. Contractures in themuscles and tendons
Equal size on both sides
of body
No contractures
Equal size on both sides of
body
No contractures
Normal
Normal